Monday, September 30, 2013

The issue of electronic cigarettes is a complex one and there is plenty of room for - and in fact a need for - vigorous discussion and debate on both sides of the issue. However, what I don't believe there is room for is tobacco control scientists and government agency leaders making up scientific evidence to support pre-determined positions. Science, not ideology, should be guiding the complex decisions that need to be made regarding the handling of the electronic cigarette issue.

Unfortunately, it appears that last week two prominent public health and tobacco control figures fabricated scientific evidence to bolster their opposition to electronic cigarettes.

1. CDC Director Dr. Thomas Frieden Stated that Many Youths Have Started Smoking Because of Electronic Cigarettes

In an interview with Medscape, CDC Director Dr. Thomas Frieden stated that many youth have become cigarette smokers because they experimented with electronic cigarettes, which then led to their smoking initiation.

Specifically, Dr. Frieden stated:

"What we are doing first is tracking, and we are seeing some very
concerning trends. Use of e-cigarettes in youth doubled just in the past
year, and many kids are starting out with e-cigarettes and then going
on to smoke conventional cigarettes."

The Rest of the Story - #1

Dr. Frieden shares two pieces of data from the CDC's tracking of electronic cigarette use among youth. First, he reports that the use of e-cigarettes in youth doubled in the past year. This statement is true, as the CDC survey did in fact show a doubling of experimentation with electronic cigarettes among youth.

The second piece of data from the survey that Dr. Frieden shares is that many of the youth smokers in the survey started as pure electronic cigarette users and that the electronic cigarette use ultimately led to their initiation of cigarette smoking.

This statement, sadly, appears to be a fabrication. The CDC survey did not show that many youth smokers actually started with e-cigarettes. In fact, the survey did not even assess that question. It measured the prevalence of smoking and electronic cigarette use among youth, but it was a cross-sectional survey and it did not track youth over time to determine their vaping and smoking patterns. Moreover, it did not collect complete smoking and vaping histories from the youth so that it could answer this question.

In other words, Dr. Frieden apparently just fabricated this evidence and presented it as being a result of the CDC's surveillance of youth e-cigarette use.

1) It is a cross-sectional survey, so it did not examine the trajectory of smoking initiation in relation to electronic cigarette use; and

2) The questionnaire only assessed ever use and past 30 day use of conventional and electronic cigarettes and it did not ascertain the longitudinal history of smoking initiation in relation to experimentation with electronic cigarettes.

Thus, in contrast to Dr. Frieden's statement, the survey provides no evidence that "many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."

Moreover, I am aware of no other scientific evidence that many youth who started out with e-cigarettes then initiated smoking.

Unfortunately, the rest of the story is that this piece of scientific evidence appears to have been fabricated to support the CDC's opposition to electronic cigarettes.

Here, I am not criticizing the CDC for its position on electronic cigarettes (that is a separate issue), but instead, I am criticizing the apparent fabrication of scientific evidence to support that position. If the evidence does not support the CDC's assertions, then the agency should not make up evidence to support those assertions. Perhaps it should instead re-think those assertions.

I believe that one of the core ethical principles of public health is honesty and transparency. Here, it appears that the CDC is being neither honest nor transparent.

In an article on electronic cigarettes in TIME magazine, Dr. Glantz is quoted as asserting that electronic cigarettes pose 10% to 20% of the risk of tobacco cigarettes, and therefore, since the risks of cigarette smoking are enormous, electronic cigarette use is a major health risk.

Specifically, Dr. Glantz is quoted as stating:

"The studies that the e-cigarette people point out, claiming that these things are harmless, are really, really, really crappy. It is probably about 10% to 20% of what a cigarette puts out, so looked at that way, they are really nice. On the other hand, if you look at absolute levels of risk, they are pretty bad, because a cigarette is just ridiculously toxic and ridiculously polluting. ... If you say an electronic cigarette is only 10% to 20% less polluting than a massive forest fire, that's not so good."

The Rest of the Story - #2

Here, Dr. Glantz has essentially fabricated scientific evidence that doesn't exist. He asserts that electronic cigarettes pose 10% to 20% of the risk of conventional cigarettes. However, no such evidence exists. Basically, he is just making this up.

If you examine the constituents in electronic cigarette vapor compared to tobacco smoke, Dr. Glantz' assertion holds no water. Cigarette smoke contains between 10,000 and 100,000 chemicals, including more than 60 known human carcinogens. Electronic cigarette vapor contains about 15 chemicals, of which only about five are of any significant health concern, and the levels of those five chemicals in electronic cigarettes are comparable to those in nicotine replacement products like the nicotine inhaler, nicotine gum, or nicotine patch.

I have argued that there are a few potential health risks associated with vaping, including long-term respiratory health effects of propylene glycol, carcinogenic effects of formaldehyde, and cardiovascular and reproductive health effects of nicotine. However, so far there is no actual scientific evidence that electronic cigarettes are causing any significant health harm to users. To assert that the risk is 10% to 20% of that of cigarettes is not only absurd, but it is just a fabrication.

If what Dr. Glantz is asserting is true, then if used over many years at the same prevalence as cigarettes, electronic cigarettes would eventually cause between 40,000 and 80,000 deaths per year. Obviously, that's a fabrication as there is no current evidence that vaping poses any significant mortality risk. What specific diseases does Dr. Glantz assert that e-cigarettes cause and what specific chemicals cause those diseases?

I would readily acknowledge that we don't have enough scientific evidence to precisely quantify the absolute risk levels associated with vaping. But that's quite the point. By asserting that the risk is 10% to 20% of that of cigarette smoking, Dr. Glantz is essentially just making up a risk estimate, without any scientific justification, support, or evidence.

Once again, the rest of the story is that another prominent tobacco control scientist appears to be fabricating scientific evidence to support a pre-determined position against electronic cigarettes. There is no room for tobacco control scientists and government agency leaders to make up
scientific evidence to support pre-determined positions. Again, science, not
ideology, should be guiding the complex decisions that need to be made
regarding the handling of the electronic cigarette issue.

Thursday, September 26, 2013

A new study published in the journal Tobacco Control reports that the graphic cigarette warning labels implemented in the UK have had no effect on smokers.

The study methodology was as follows: "The UK (UK) became the third country in the European Union to require pictorial warnings on the back of cigarette packs,
in October 2008. A repeat cross-sectional survey
was conducted with 11–16-year-olds in the UK between August and
September 2008 (N=1401) and
August and September 2011 (N=1373).
At both waves the same text warnings appeared on the front and back of
packs, with the
only difference being the inclusion
of images on the back of packs to support
the text warnings in 2011. Warning related measures
assessed were salience (noticing,
looking closely at warnings), depth of processing (thinking about
warnings, discussing them
with others), comprehension and
credibility (warning comprehensibility, believability and truthfulness),
unaided recall, persuasiveness
(warnings as a deterrent to
smoking), avoidance techniques (eg, hiding packs) and a behavioural
indicator (forgoing cigarettes
due to warnings)."

The results were as follows: "For never smokers, warning persuasiveness and thinking about what
warnings are telling them when the pack is in sight significantly
increased from 2008 to 2011, but
warning comprehensibility significantly decreased. For experimental
smokers, there was a
significant increase from 2008 to
2011 for warning persuasiveness, believing warnings and considering them
truthful. For regular smokers, there were no significant changes from 2008 to 2011, except for an increase in hiding packs to avoid warnings and
a decrease in warning salience."

The Rest of the Story

This research adds to the growing body of literature which suggest that graphic cigarette warning labels are largely ineffective, having a negligible effect on smokers. In this study, the warning labels were found not to have increased smoking cessation or even smoking reduction among smokers. Among nonsmokers, there was actually a decrease in warning comprehensibility, although persuasiveness increased.

Overall, these results suggest that the graphic warning labels had only marginal effects, with no effect on smokers.

This is not the kind of evidence that the FDA is going to need in court to support its plan to impose graphic warning labels on cigarettes.

Wednesday, September 25, 2013

A new study published in the journal Addictive Behaviors confirms the conclusion of last week's CDC study: the use of electronic cigarettes among nonsmoking youth is extremely low.

In fact, of a high school population of 1,345 students, the survey could find only 5 nonsmokers who had experimented with e-cigarettes in the past 30 days.

In the first wave of the survey (February 2010), a total of 1,719
students were surveyed. The total number of nonsmokers who had
experimented with e-cigarettes in the past 30 days was 2.

In the second wave of the survey (October 2010), a total of 1,702
students were surveyed. The total number of nonsmokers who had
experimented with e-cigarettes in the past 30 days was 5.

In the most recent wave of the survey (June 2011), a total of 1,345 students were surveyed. The total number of nonsmokers who had experimented with e-cigarettes in the past 30 days was 5.

Thus, the percentage of nonsmoking e-cigarette users among this high school sample was 0.1% at wave 1, 0.3% at wave 2, and 0.4% at wave 3.

The estimated percentage of nonsmoking e-cigarette users among youth nationally in the CDC survey was approximately 0.5%, suggesting that we are not seeing a substantial increase in the use of electronic cigarettes among nonsmoking youth.

Not surprisingly, the study does not actually directly mention the very low use of electronic cigarettes by nonsmoking youth and does not point out that the evidence it presents suggests that there is currently no reason for major concern that e-cigarettes are serving as a gateway to youth smoking.

The Rest of the Story

This study adds to the evidence that electronic cigarette use among nonsmoking youth is not currently a significant problem and that these products are not serving as a gateway to cigarette smoking, as claimed by many anti-smoking groups as well as policy makers.

Last week, Senator Ed Markey (D-MA) stated: "These e-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth."

Connecticut Senator Richard Blumenthal stated as follows:
"“Electronic cigarettes as marketed today – with flavors like
bubblegum and strawberry – are targeted at young people with the very
clear intent of creating a new generation of smokers. Without question,
tobacco companies are using the same despicable tactics with
e-cigarettes that they used in previous decades with traditional
cigarettes to lure youth down a path of nicotine addiction and eventual
death."

And CDC Director Dr. Thomas Frieden proclaimed: "The increased use of e-cigarettes by teens is deeply
troubling....Nicotine is a highly addictive drug. Many teens who
start with e-cigarettes may be condemned to struggling with a
lifelong addiction to nicotine and conventional cigarettes."

This study, along with CDC's own study, demonstrates that these public health advocates and politicians are merely blowing smoke. They are not basing their statements on scientific evidence but are apparently jumping at the opportunity to lash out at electronic cigarettes, about which they presumably have reached a pre-determined conclusion based on ideology, not science.

The 0.4% prevalence of nonsmoking youth who have experimented with e-cigarettes in the past 30 days is even less concerning when you consider that this merely represents the use of an e-cigarette in the past month. It does not necessarily indicate regular use of the product, adoption of vaping as a regular behavior, or addiction to nicotine. In fact, the absence of major observed increases in the prevalence of e-cigarette use among nonsmoking youth suggests that at the current time, this behavior holds little appeal for them.

It is now clear that neither of the two potential drawbacks to the promotion of e-cigarettes - the inhibition of quitting by smokers and the initiation of smoking by nonsmokers - are significant problems at the present time. Therefore, it is quite clear that the net public health impact of electronic cigarettes is a positive one.

While FDA regulation is necessary to make sure that e-cigarettes remain out of reach and/or out of favor among nonsmoking youth, the scientific evidence supports the contention that the FDA, along with anti-smoking groups and advocates, should embrace electronic cigarettes as an important strategy in their efforts to reduce smoking and its related health consequences.

Tuesday, September 24, 2013

Bonnie Herzog, a tobacco financial analyst with Wells Fargo, has predicted that by 2021, sales of electronic cigarettes will actually surpass those of tobacco cigarettes, according to an article at NACS Online.

According to the article: "Herzog said that U.S. e-cigarette sales will reach roughly $2 billion
by the end of this year and up to $10 billion by 2017. She expects
Altria, R.J. Reynolds and Lorillard to take an increasing presence in
the category, which will accelerate its growth. Herzog based her projection on three factors: The manufacturers’
ability to invest in the electronic cigarettes; their supply chain
relationships with retailers and distributors; and their expertise at
building successful brands. ... However, Herzog’s predictions can be upset by the FDA’s decision to
regulate electronic cigarettes, said Carl Philips, scientific director
for Consumer Advocates for Smoke-free Alternatives Association. 'We
remain cautiously optimistic that the regulations will favor consumers
and public health, which will mean not imposing the restrictions that
favor large manufacturers.'"

The Rest of the Story

If Herzog's prediction is true, then electronic cigarettes may be one of the most effective public health interventions of all time. to reduce the sale of tobacco cigarettes so much that it is surpassed by electronic cigarettes would represent a drastic reduction in cigarette consumption and a tremendous accomplishment in terms of disease averted and lives saved.

Ironically, as Carl Phillips points out, the primary obstacle to this positive scenario is the anti-smoking establishment and its efforts to derail the electronic cigarette movement. If embraced by the FDA, this could result in a major obstacle for the expansion of the e-cigarette market, and therefore, for the decrease in the tobacco cigarette market.

Already, the sale of electronic cigarettes has resulted in unexpected declines in cigarette sales. What I don't understand is why anti-smoking groups continue to fail to appreciate that this is a demonstrable public health gain. The burden of cigarette-related disease and death is directly proportional to levels of cigarette consumption. Some of the major anti-smoking groups and advocates fail to understand that basic equation.

While there is no question that appropriate regulation of electronic cigarettes is necessary to keep these products out of the hands of minors and to ensure uniform quality and safety standards, the current evidence strongly suggests that electronic cigarettes have the potential to greatly benefit the public's health. It is unfortunate that such gains are going to be realized despite the efforts of anti-smoking groups rather than because of their efforts.

Monday, September 23, 2013

Apparently, the American Heart Association is not sure if there are benefits to quitting smoking if you continue to inhale nicotine, such as you would do if you quit by using electronic cigarettes or a nicotine inhaler and then continued to use those devices.

According to the chief medical officer of the American Heart Association, as quoted at WebMD: "They [electronic cigarettes] are nicotine delivery devices intended to be used like a cigarette. What happens to someone who stops inhaling the tars of cigarettes and inhales only nicotine? We don't know."

This is quite clearly a caution against quitting smoking using nicotine inhalers because smokers doing so are stopping inhaling the tars of cigarettes but still inhaling nicotine. The same is true with electronic cigarettes.

The Rest of the Story

The American Heart Association would have us believe that there is not enough scientific evidence to know what happens to a person who quits smoking - thus eliminating their exposure to cigarette tars - but who continues to obtain nicotine (but in a "clean" fashion).

The rest of the story is that we know full well what happens to that person: they greatly reduce their risk of disease and death and quite possibly, they save their life.

How in 2013 the American Heart Association could not be aware that it is the tar (with the tens of thousands of chemicals and more than 60 known carcinogens), not the nicotine, which causes the overwhelming bulk of smoking-related disease is completely beyond me.

Shockingly, in 2013, it is the anti-smoking groups - not the tobacco companies - which are misleading the public about the health effects of smoking and undermining the public's appreciation of those hazards. Ironically, and quite sadly, the tobacco companies historical efforts to lie to and mislead the public in order to undermine the public's appreciation of the severe hazards of smoking have been replaced by the efforts of major anti-smoking groups.

And all this because these anti-smoking groups are so blinded by ideology that they are unable to endorse a behavior that looks like smoking, even though it protects the user from virtually all of its associated health effects.

Thursday, September 19, 2013

I hate to start another post with "Yes, you read that headline correctly," but indeed, you did read the headline correctly.

The FDA has acknowledged that it does not want the public to think that cigarette smoking is any more hazardous than using a non-tobacco e-cigarette.

According to an FDA spokeswoman, as quoted at WebMD: "We don't want the public to perceive them (e-cigarettes) as a safer alternative to cigarettes."

The Rest of the Story

Why in the world does the FDA want the public to think that cigarette smoking is no more hazardous than vaping?

Even the tobacco industry, in 2013, acknowledges that smoking is more harmful than vaping.

In fact, if a tobacco company made the very same assertion that the FDA is making, they would immediately be dragged back into Judge Kessler's courtroom and would have to issue yet another corrective statement.

To be sure, then, the FDA should be ordered to issue a corrective statement of its own. Here is my suggestion:

We
are being required to tell the truth about the safety of cigarettes compared to electronic cigarettes. We told
you that electronic cigarettes were no safer than tobacco cigarettes, that we didn't want you to think that e-cigarettes were safer. But that was a lie. Here's the truth:

We
found only trace levels of tobacco-specific nitrosamines in electronic
cigarettes, comparable to those found in FDA-approved nicotine
replacement products like nicotine patches and nicotine gum. In contrast, cigarettes have high levels of tobacco-specific nitrosamines and pose a substantial cancer risk.

The
levels of carcinogens we detected in electronic cigarettes are orders
of magnitude lower than in regular cigarettes, indicating that
electronic cigarettes are likely much safer than regular cigarettes in
terms of cancer risk.

The minute levels of tobacco-specific
nitrosamines in electronic cigarettes are a necessary result of the
extraction of nicotine from tobacco. Overall, these devices deliver
nicotine with only a few other chemicals, compared to the delivery of
nicotine plus tens of thousands of chemicals and more than 60 proven
carcinogens in regular cigarettes.

Recent studies have shown that in contrast to smoking, e-cigarette use does not cause acute impairment of the coronary circulation. Thus, the risks of heart disease are likely to be much lower.

Smokers who switch to electronic cigarettes have been shown to have an immediate improvement in their respiratory symptoms. E-cigarettes almost certainly lower the risk of COPD compared to continued smoking.

Paid for by the Food and Drug Administration by order of The Rest of the Story.

Wednesday, September 18, 2013

A prominent anti-smoking researcher and advocate is promoting "anti-smoking" campaigns that actually discourage many smokers from quitting.

Specifically, Dr. Stan Glantz wants anti-smoking campaigns to include anti-e-cigarette messages as well. He has called for anti-smoking campaigns that actively discourage smokers from quitting - at least those smokers who are thinking of quitting using e-cigarettes.

On his tobacco blog, Glantz offers the following recommendation: "States need to include ecigs in their anti-tobacco marketing campaigns, especially the fact that they pollute the air."

The effect of this message would be to discourage all electronic cigarette use, hindering or preventing literally thousands of smokers from quitting.

The Rest of the Story

You know that your movement is deteriorating when one of its prominent advocates wants anti-smoking campaigns that actively discourage thousands of smokers from quitting just because he has some sort of ideological opposition to a smoking cessation device that looks like a cigarette.

Look - there are many legitimate areas of uncertainty and disagreement about electronic cigarettes, including details about how they should be regulated, their long-term effects, the extent of their use by minors, whether they should be allowed in places where smoking is banned, etc. However, so far, only anti-smoking groups have actively discouraged people from quitting smoking using these devices. Only anti-smoking groups have condemned people who have literally saved their lives by quitting smoking, condemning them simply because they didn't quit "the right way." Only a movement that has become divorced from its public health objectives could be so blinded by ideology that it begins promoting policies and programs that will destroy its own goals.

Tuesday, September 17, 2013

In a recent blog post, Dr. Stan Glantz argues that heavy promotion of electronic cigarettes will increase, rather than decrease, the toll of nicotine addiction.

Question for my readers: Which of the following is the evidence upon which Dr. Glantz puts forward his argument?

A. A review of clinical trials on the effectiveness of electronic cigarettes.
B. A review of laboratory studies of the chemical constituents of electronic cigarette vapor.
C. A review of survey evidence of youth use of electronic cigarettes.
D. All of the above.
E. A weighing of the potential health benefits and costs of promoting electronic cigarettes.
F. Comments made by two anonymous blog commenters.

The Rest of the Story

To see how low we have gone, the answer to the question is:

F. Comments made by two anonymous blog commenters.

It is sad to me that this is where we are at now. A major anti-smoking researcher offers a widely-disseminated public opinion about the net benefits of electronic cigarettes to the overall public health of the nation, and his opinion is based on the rantings of two anonymous blog commenters!

Clearly, this is someone who has drawn a pre-determined conclusion about electronic cigarettes and their net impact on the public's health and who is not interested in serious consideration of this issue on anything close to a scientific basis.

It truly saddens me to see to depths to which the anti-smoking movement has deteriorated.

The issue of the net impact of the marketing of electronic cigarettes on the public's health is a complex one that, at a minimum, involves a consideration of:

the likely number of smokers who will quit smoking as a result of electronic cigarette promotion;

the safety advantages of electronic cigarettes over continued smoking;

the natural history of smoking in the absence of an electronic cigarette trial;

the uptake of electronic cigarettes by nonsmoking youth and the extent of progression to established smoking.

But apparently it's a lot simpler for some anti-smoking researchers. The whole question can be answered by two blog rants by Patricia and Stig.

Monday, September 16, 2013

A number of anti-smoking advocates continue to make the assertion that electronic cigarette company marketing is promoting cigarette smoking.

For example, in response
to a CDC report on youth experimentation with e-cigarettes, Connecticut Senator Richard Blumenthal
stated as follows: "“Electronic cigarettes as marketed today – with
flavors like
bubblegum and strawberry – are targeted at young people with the very
clear intent of creating a new generation of smokers. Without question,
tobacco companies are using the same despicable tactics with
e-cigarettes that they used in previous decades with traditional
cigarettes to lure youth down a path of nicotine addiction and eventual
death."

In an article published in JAMA, Benowitz and Goniewicz argued that marketing of electronic cigarettes may promote "continued smoking of cigarettes and renormalizing cigarette smoking behaviours."

The Philippines health director stated that: "the electronic cigarette promotes smoking among children and the youth.
It makes them less fearful of hazards and risks of smoking. It is
opposed to the DOH’s health goal to stop cigarette smoking and tobacco
use."

These are just a few examples of the many anti-smoking advocates and groups which are claiming that electronic cigarette companies are marketing their products in order to promote smoking.

The Rest of the Story

I have already pointed out how ridiculous this assertion is. But I think it deserves some more emphasis.

The clear intention of electronic cigarette marketers is to sell
as many electronic cigarettes as they can, not as many cigarettes
as they can. In fact, of the more than 250 companies now on the
general market, only one even sells cigarettes in the first place.
Thus, it is preposterous to assert that electronic cigarette marketing is intended to promote cigarette smoking.

The truth is exactly the opposite. What electronic cigarette companies want is to get smokers to quit smoking and switch to electronic cigarettes instead. The greater the degree of substitution of e-cigarettes for the real ones, the more money the e-cigarette companies make. Thus, they have no incentive to encourage smokers to maintain their smoking behavior.

In short, at least for 249 of the 250 electronic cigarette companies that are currently selling on the general market, there is zero incentive for them to promote continued smoking and none of them are doing that.

My examination of marketing for the only company (Blu cigs, owned by Lorillard) which could conceivably have an incentive to promote continued smoking - in addition to e-cigarette use - confirms that they are not in any way promoting smoking. What they are promoting is electronic cigarette use.

This has to be one of the most inane assertions being made by anti-smoking groups and advocates that I have ever heard.

Thursday, September 12, 2013

Yesterday, I had the pleasure of appearing as a guest on "On Point" with Tom Ashbrook, along with my mentor, Dr. Stan Glantz. The segment featured a general discussion of the potential role of electronic cigarettes in relation to public health. You can listen to the segment here.

The Rest of the Story
The most surprising aspect of the segment to me was Dr. Glantz' assertion that not only are electronic cigarettes ineffective for smoking cessation, but that they actually inhibit smoking cessation. He based this assertion on a study that he has misinterpreted, as I have explained previously. Moreover, he made this assertion in the face of his own acknowledgment that a clinical trial published just last week showed that electronic cigarettes are as effective as the nicotine patch for smoking cessation. If electronic cigarettes are equally effective as NRT for smoking cessation, then how can he possibly claim that e-cigarettes inhibit smoking cessation?

The most disappointing aspect of the segment, in addition to Dr. Glantz' misrepresentation of the Vickerman study, was his attempt to scare the public about the dangers of e-cigarettes by noting that they contain tobacco-specific nitrosamines. But what Dr. Glantz did not tell listeners was that these are trace levels, that they are an inevitable artifact of the derivation of nicotine from tobacco, that the same levels of tobacco-specific nitrosamines are present in nicotine gum and nicotine patches, and that these trace levels pose no health threat, just as they pose no health threat to users of nicotine patches and gum.

The most disturbing aspect of the segment was Dr. Glantz' dismissal of the tremendous health accomplishments made by the many callers (and thousands of similar people in the same situations) who have literally saved their lives by quitting smoking using e-cigs, or who have taken a serious step towards quitting smoking by greatly reducing their cigarette intake.

The saddest aspect of the segment was hearing my mentor support the availability and marketing of FDA-approved cigarettes which are killing hundreds of thousands of Americans each year, yet wanting to restrict or eliminate access to electronic cigarettes, a much safer alternative that contains no tobacco and involves no combustion.

Unlike Dr. Glantz, I think we should be promoting electronic cigarettes and discouraging the real ones rather than ensuring that people continue to assume the known risks of tobacco cigarettes rather than take a chance on the assuredly much safer fake ones.

Wednesday, September 11, 2013

A group of U.S. Senators earlier this week lambasted electronic cigarettes and their flavorings, calling them a gateway to cigarette use and proclaiming themselves public health champions who will do what is necessary to protect kids from cigarette addiction.

For example, Senator Dick Durbin (D-IL) boasted: "This scientific report provides conclusive evidence that the use of
e-cigarettes among our nation’s kids is both on the rise and closely
linked to the deadly use of cigarettes. This information is a call to
action – tobacco companies continue to find new ways to target America’s
young people and we need to actively prevent it. I commend the Centers
for Disease Control for shedding light on this important issue, and look
forward to working with my colleagues to continue work to curb tobacco
use amongst our kids. With the right commitment we can spare future
generations of young people from this deadly epidemic."

At the same time, the Campaign for Tobacco-Free Kids jumped on the new CDC data and demanded instant action by the FDA to stop the marketing of these flavored products to children, complaining that "e-cigarettes are sold in an assortment of sweet, kid-friendly flavors including “vivid vanilla,” “cherry crush” and chocolate." The Campaign then boldly called for the federal and state governments "to take action to protect our kids."

The Rest of the Story

The rest of the story is that these politicians as well as the Campaign for Tobacco-Free Kids are full of baloney. While these politicians and anti-smoking groups are boasting about how committed they are to protect kids from a flavored product that might, through a tortuous pathway, eventually lead to cigarette smoking, these very same politicians and groups opposed protecting kids from addiction to cigarettes by banning the very flavored cigarettes that youth are actually smoking in huge numbers.

Yes, it is sadly true that Senator Durbin, along with the Campaign for Tobacco-Free Kids, led efforts to block the regulation of menthol cigarettes at the same time that Congress was banning every other cigarette flavor under the sun. Ironically, every one of these flavors except menthol was not actually smoked by youth. But menthol cigarettes were the flavor of choice among youth smokers.

Why did Senator Durbin and the Campaign for Tobacco-Free Kids oppose a ban on menthol cigarettes? Very simple: Because a menthol ban would have actually made a dent in cigarette sales. Unlike the enacted ban on cherry cigarettes which these groups endorsed, a ban on menthol cigarettes would actually have reduced youth smoking substantially.

So Senator Durbin and the Campaign for Tobacco-Free Kids and all of their friends in Congress who pretended to stand up against Big Tobacco actually did just the opposite: they fought the tobacco companies only to the point where it would have actually started hurting these corporations in the pocket book and thereby improving the public's health. It was an act of supreme hypocrisy and immense political cowardice.

While Durbin and the Campaign were busy flexing their muscles and touting their concern for kids, another piece of relevant data came out earlier this week. A study published in the journal Tobacco Control reported that 57% of youth smokers smoke menthol cigarettes and that menthol cigarettes are much more popular among youth smokers than among adults.

The report noted that while the smoking of non-menthol cigarettes among youth has declined, rates of menthol smoking have remained high and constant. The researchers concluded that the continued marketing of menthol cigarettes - facilitated by none other than Senator Durbin and the Campaign for Tobacco-Free Kids - has undermined progress in reducing youth smoking, writing that "Progress in reducing youth smoking has likely been attenuated by the sale and marketing of mentholated cigarettes, including emerging varieties of established youth brands."

Thus, instead of being champions for the public's health, firm opponents of Big Tobacco, and protectors of youth from cigarette addiction, Senator Durbin and friends along with the Campaign for Tobacco-Free Kids and its friends have actually been the cause of failure to make as much progress in reducing youth smoking. In other words, they are not public health champions, but hypocrites.

To make matters much worse, in caving in to Big Tobacco and protecting cigarette sales to youth, the Campaign for Tobacco-Free Kids advanced the racist and scientifically unsupported "justification" that African American smokers would turn to contraband. In fact, the Campaign for Tobacco-Free Kids advanced this argument before Lorillard did. In fact, Lorillard didn't have to make the argument because the Campaign for Tobacco-Free Kids already had. And it was this argument which the Campaign used to block an amendment which would have removed the menthol exemption.

The Campaign for Tobacco-Free Kids actually did Lorillard's dirty work for it. Part of its lobbying expenditures really should have been reported under Lorillard.

It is bad enough that politicians and a major tobacco control group have sold out the health of America's children, and in particular - African-American smokers - in order to protect the profits of tobacco companies. But seeing these same politicians and groups now pretend that protecting kids from addiction to flavored addictive products is their principled priority is too much for this stomach to handle.

Tuesday, September 10, 2013

According to a press release issued Monday, the University of Kentucky Markey Cancer Center testified before the state legislature that smoking is no more harmful than vaping.

Yes, you read that correctly.

The University of Kentucky Cancer Center apparently testified that smoking - which kills 400,000 people each year in the U.S. - is no more hazardous than vaping, which involves no tobacco and no combustion and merely involves the vaporization of nicotine from a solution containing propylene glycol and glycerin.

According to the press release, which appears to have been issued by Kentucky Lung Cancer Research Program, the University of Kentucky Cancer Center director - Dr. Mark Evers - told a state legislative panel that e-cigarettes may be "every bit as dangerous" as smoking tobacco.

The Rest of the Story

Let's be very straight about this: if the tobacco companies said exactly the same thing before the legislature, they would probably be facing criminal charges for perjury, as well as civil liability charges for fraud.

For any tobacco company to defraud the American public by undermining the health consequences of smoking by stating that they are no more harmful than electronic cigarettes would be unheard of in 2013, and no tobacco company would ever do such a thing. They wouldn't be caught dead making such an outright lie.

Apparently, this is not so for the University of Kentucky Cancer Center, which stepped into territory that used to be occupied by Big Tobacco, lying before a state legislative panel, asserting that vaping is every bit as dangerous as smoking.

Even the tobacco companies agree that smoking is more hazardous than vaping. I don't understand how any scientist, especially a physician at a cancer center, could downplay the hazards of smoking so much as to suggest that they are no more harmful than a product that contains no tobacco and involves no combustion.

What is it about electronic cigarettes that causes its opponents to consistently lie to the public and make up scientific data to support their opposition? My guess is that the evidence is simply too strong for them to confront directly and honestly. Why else the need to resort to lying or misleading the public?

Monday, September 09, 2013

The Centers for Disease Control and Prevention (CDC) reported last week that the prevalence of youth in grades 6-12 who have experimented with electronic cigarettes in the past month increased from 1.1% in 2011 to 2.1% in 2012. Among middle school students, the prevalence of past month use increased from 0.6% to 1.1%. Among high school students, past-month use increased from 1.5% to 2.8%.

Based on these results, CDC Director Dr. Thomas Frieden proclaimed: "The increased use of e-cigarettes by teens is deeply
troubling....Nicotine is a highly addictive drug. Many teens who
start with e-cigarettes may be condemned to struggling with a
lifelong addiction to nicotine and conventional cigarettes."

In response to the CDC report, Connecticut Attorney General Richard Blumenthal stated as follows: "“Electronic cigarettes as marketed today – with flavors like
bubblegum and strawberry – are targeted at young people with the very
clear intent of creating a new generation of smokers. Without question,
tobacco companies are using the same despicable tactics with
e-cigarettes that they used in previous decades with traditional
cigarettes to lure youth down a path of nicotine addiction and eventual
death."

Senator Markey responded: "“These e-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth."

The Rest of the Story

The alarm calls being made by public health officials and politicians are premature. And their conclusions are unsupported by these data.

In no way do these data support the hypothesis that electronic cigarettes are a "gateway to tobacco use" by children and teens as Senator Markey claims. And there is no evidence provided that electronic cigarettes are being "targeted at young people with the very clear intent of creating a new generation of smokers" as Attorney General Blumenthal claims.

It is not at all surprising that youth smokers might experiment with electronic cigarettes. To the extent that these youth are able to switch over to electronic cigarettes, they are most likely reducing their long-term prospects of becoming cigarette smoking addicts. The danger is if nonsmoking youth start using these products and then end up becoming addicted to nicotine, causing them to transition to cigarette smoking.

But what do the CDC data tell us about whether the kids experimenting with e-cigarettes are smokers or nonsmokers?

Among youth who experimented with electronic cigarettes in 2012, the overwhelming majority - 90.6% - were smokers.Only about one in ten of the youths who experimented with electronic cigarettes were never smokers. And among the high school students who tried electronic cigarettes, only 7.2% were never smokers. Thus, it is quite clear that the overwhelming majority of the experimentation that is occurring among youth is happening among youth who already smoke cigarettes. This is not necessarily a bad thing, on its own, if it can reduce the chances of these youths becoming lifelong cigarette addicts.

The proportion of nonsmoking youth who experimented with e-cigarettes in the past 30 days remains small:

Overall, only 0.5% of youth were nonsmokers using e-cigarettes in the past 30 days;

Among middle school students, only 0.4% were nonsmokers using e-cigarettes in the past 30 days; and

Among high school students, only 0.5% were nonsmokers using e-cigarettes in the past 30 days.

There are three other important points that make up the rest of the story.

1. The survey measured experimentation, but not regular e-cigarette use.

It is not surprising that about 2% of youth would try electronic cigarettes. But the important issue is what percentage of these youth enjoy them enough to become regular users? The CDC survey measured past month use (which is essentially experimentation), but it did not assess daily use, or anything close to regular use. So what we end up with is a measure of experimentation, but no idea of whether youth are actually taking up this behavior and becoming regular vapers.

2. The survey found no evidence that e-cigarettes are a gateway to smoking.

In contrast to the alarming statements of the politicians and the CDC director (who was talking more like a politician), the survey provided no evidence whatsoever that electronic cigarettes are serving as a gateway to cigarette use. Not a single case was documented in which a nonsmoking youth began using electronic cigarettes, became addicted to nicotine, and then went on to become a regular cigarette smoker. So we're still in the realm of unsubstantiated claims.

3. The low rates of youth nonsmoker use of e-cigarettes in light of the high rates of experimentation with e-cigarettes among youth suggest that e-cigarettes are not currently a major problem that is creating a gateway to increased cigarette addiction.

Given that the rate of experimentation with electronic cigarettes is as high as 10% among high school students, the finding that only 0.5% of high school students are nonsmoking, current electronic cigarette users is actually somewhat reassuring. It suggests that this behavior has not caught on among nonsmokers -- at least not yet.

4. Neither this study, nor other evidence, supports the assertion that electronic cigarettes are being marketed with the intention of recruiting youth and/or creating new cigarette smokers from those youth.

It is difficult to refute a statement for which there is no evidence presented in support. Attorney General Blumenthal claims that electronic cigarettes "are targeted at young people with the very
clear intent of creating a new generation of smokers." However, he provides not a shred of evidence to support this outcontention. Perhaps in political circles, that flies. But in science, it does not. I cannot make a statement like that with providing at least some supporting evidence.

In fact, the existing evidence refutes Blumenthal's contention, because the clear intention of electronic cigarette marketers is to sell as many electronic cigarettes as they can, not as many cigarettes as they can. In fact, of the more than 250 companies now on the general market, only one even sells cigarettes in the first place. Blumenthal's assertion, therefore, is not only unsubstantiated, but preposterous.

Summary

The rest of the story is that both health leaders and politicians (perhaps being one in the same) are using these data to make false and exaggerated claims that have no basis in science. There is no evidence that regular electronic cigarette use is becoming a substantial problem among youth nonsmokers and there remains no evidence that electronic cigarettes have become a gateway to cigarette addiction. These is also no evidence that these products are being marketed with the intention of turning youth into new cigarette smokers.

Nevertheless, I am in no way arguing here that regulation is not needed. Just the opposite. The FDA needs to step in and do everything it reasonably can to ensure that electronic cigarettes do not become popular among youth, and especially that they do not become a gateway to nicotine addiction and cigarette use.

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.